PowerPoint Presentation · Women with pregestational diabetes who also have PCOS may continue...

29/01/2014

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Canadian Diabetes Association

Clinical Practice Guidelines

Pregnancy

Chapter 36

David Thompson, Howard Berger,

Denice Feig, Robert Gagnon, Tina Kader,

Erin Keely, Sharon Kozak, Edmond Ryan,

Mathew Sermer, Christina Vinokuroff

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association

In collaboration with …



Diabetes in Pregnancy: 2 Categories

Pregestational diabetes Gestational diabetes

Pregnancy in

pre-existing diabetes

• Type 1 diabetes

• Type 2 diabetes

Diabetes diagnosed in

pregnancy

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Need a Preconception Checklist for

Women with Pre-existing Diabetes

1. Attain a preconception A1C of ≤7.0% (if safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 5 mg/d: 3 months pre-conception to 12

weeks post-conception

5. Discontinue potential embryopathic meds:

Ace-inhibitors/ARB (prior to or upon detection of pregnancy)

Statin therapy

2013



Recommendations 1-2: Preconception Care

1. All women of reproductive age with type 1 or type 2

diabetes should receive advice on reliable birth control,

the importance of glycemic control prior to pregnancy,

impact of BMI on pregnancy outcomes, need for folic

acid and the need to stop potentially embyropathic

drugs prior to pregnancy [Grade D, Level 4].

2. Women with type 2 diabetes and irregular

menses/PCOS who are started on metformin or a

thiazolidinedione should be advised that fertility may

improve and be warned about possible pregnancy [Grade D,

Consensus].

2013



Recommendation 3: Preconception Care

3. Before attempting to become pregnant, women

with type 1 or type 2 diabetes should:

a) Receive preconception counseling that

includes optimal diabetes management and

nutrition, preferably in consultation with an

interdisciplinary pregnancy team to optimize

maternal and neonatal outcomes [Grade C, Level 3]

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(continued)

b) Strive to attain a preconception A1C of ≤7.0% (or

A1C as close to normal as can safely be achieved)

to decrease the risk of:

– Spontaneous abortion [Grade C, Level 3]

– Congenital anomalies [Grade C, Level 3]

– Pre-eclampsia [Grade C, Level 3]

– Progression of retinopathy in pregnancy [Grade A, level

1 for type 1 diabetes (23); Grade D, Consensus for type 2 diabetes]



c) Supplement their diet with multivitamins containing

5 mg of folic acid at least 3 months pre-

conception and continuing until at least 12 weeks

post-conception [Grade D, Level 4]. Supplementation

should continue with a multivitamin containing 0.4-

1.0 mg of folic acid from 12 weeks

postconception through to 6 weeks postpartum

or as long as breastfeeding continues [Grade D,

Consensus].


(continued)



d) Discontinue medications that are potentially

embryopathic, including any from the following

classes:

• ACE inhibitors and ARBs prior to conception

or upon detection of pregnancy [Grade C, Level 3]

• Statins [Grade D, Level 4]

2013


(continued)

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4. Women with type 2 diabetes who are planning a

pregnancy should switch from non-insulin

antihyperglycemic agents to insulin for glycemic

control [Grade D, Consensus].

Women with pregestational diabetes who also

have PCOS may continue metformin for

ovulation induction [Grade D, Consensus].




Recommendations 5 and 6: Preconception

and Complications

5. Women should undergo an ophthalmological

evaluation by an eye care specialist [Grade A, Level 1, for

type 1; Grade D, Level 4 for type 2].

6. Women should be screened for chronic kidney

disease prior to pregnancy [Grade D level 4 for type 1 diabetes

Grade D, consensus for type 2 diabetes]. Women with

microalbuminuria or overt nephropathy are at

increased risk for the development of HTN and

preeclampsia [Grade A level 1]; and should be followed

closely for these conditions [Grade D, Consensus]



Recommendation 7: Management in

Pregnancy for Pregestational Diabetes

7. Pregnant women with type 1 or type 2 diabetes

should:

a) Receive an individualized insulin regimen and

glycemic targets typically using intensive insulin

therapy [Grade A, Level 1B for type 1; Grade A, Level 1 for type 2]

b) Strive for target glucose values [Grade D consensus]:

• Fasting PG below 5.3 mmol/L

• 1h postprandial below 7.8 mmol/L

• 2h postprandial below 6.7 mmol/L

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Recommendation 7: Management in Pregnancy

for Pre-gestational Diabetes (continued)

c) Be prepared to raise these targets if need be

because of the increased risk of severe

hypoglycemia during pregnancy [Grade D, Consensus]

d) Perform SMBG, both pre- and postprandially

to achieve glycemic targets and improve

pregnancy outcomes [Grade C, Level 3]

2013



10.Women should be closely monitored during labour

and delivery and maternal blood glucose levels

should be kept between 4.0 and 7.0 mmol/L in

order to minimize the risk of neonatal hypoglycemia [Grade D, Consensus]

11.Women should receive adequate glucose during

labour in order to meet the high energy requirements [Grade D, Consensus]

Recommendation 10 and 11: Intrapartum

Glucose Management

2013

2013



Recommendations 12 and 13: Postpartum

Glucose Management

12.Women with pregestational diabetes should be

carefully monitored postpartum as they have a

high risk of hypoglycemia [Grade D, Consensus].

13.Metformin and glyburide may be used during

breast-feeding [Grade C, Level 3 for metformin; Grade D, Level 4 for

glyburide].

2013

2013

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Recommendation 14 and 15: Postpartum

Glucose Management

14.Women with type 1 diabetes in pregnancy should

be screened for postpartum thyroiditis with a TSH

test at 6-8 weeks postpartum [Grade D, Consensus].

15.All women should be encouraged to breast-feed,

since this may reduce offspring obesity, especially in

the setting of maternal obesity [Grade C level 3-]



Gestational Diabetes (GDM) Diagnosis

• Universal screening for GDM @ 24-28 weeks

Gestational Age (GA)

• Screen earlier if risk factors for GDM:

Previous GDM BMI ≥30 kg/m2

Prediabetes Polycystic ovarian syndrome

High risk population

(Aboriginal, Hispanic, South

Asian, Asian, African)

Current fetal macrosomia or

polyhydramnios

Age ≥35 years History of macrosomic infant

Corticosteroid use

Acanthosis nigricans



Why Diagnose and Treat GDM?

• Macrosomia

• Shoulder dystocia and

nerve injury

• Neonatal hypoglycemia

• Preterm delivery

• Hyperbilirubinemia

• Caesarian section

• Offspring obesity (?)

• Offspring diabetes (?)

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Benefits of Treatment of GDM



Benefits of Treatment of GDM

Horvath K et al. BMJ 2010;340:c1935



Are there clear threshold glucose levels

above which the risk of adverse neonatal

or maternal outcomes increases?

Diagnosis of GDM

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Are there clear threshold glucose levels

above which the risk of adverse neonatal

or maternal outcomes increases?



Threshold glucose

levels (mmol/L) after

a 75g OGTT

OR 1.75 OR 2.0

Fasting plasma

glucose 5.1 5.3

1-h plasma glucose 10.0 10.6

2-h plasma glucose 8.5 9.0

% of cohort that met

≥ 1 threshold above 16.1% 8.8%

Odds Ratio (OR) of 1.75 vs. 2.0 for Primary

Outcome in HAPO

OGTT = Oral Glucose Tolerance Test

HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study

IADPSG. Diabetes Care 2010;22:676-682



Considerations for the CDA Adopting the

IADPSG Thresholds

• How can we select an odds ratio threshold in the

absence of a true threshold in the data?

• What is the impact on the patient and workload of

increasing the prevalence of GDM?

• Do we have sufficient evidence with respect to

treatment benefit at the various thresholds to make

an informed decision?

• In the absence of clear benefit, should the diagnostic

criteria be changed from 2008?

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2013 GDM Diagnosis: Two Approaches 2013



Recommendations 16-17: Diagnosis of GDM

16.All pregnant women should be screened for GDM

at 24-28 weeks of gestation [Grade C, Level 3].

17.If there is a high risk of GDM based on multiple

clinical factors, screening should be offered at any

stage in the pregnancy [Grade D, Consensus]. If the initial

screening is performed before 24 weeks of

gestation and is negative, rescreen between 24-28

weeks of gestation. (see next slide)



Recommendation 17: Risk Factors for GDM

(continued)

• Age ≥35 years

• Previous GDM

• Prediabetes

• High risk population

– Aboriginal, Hispanic, South

Asian, Asian, African

• BMI ≥30 kg/m2

• Polycystic ovarian

syndrome

• Acanthosis nigricans

• Corticosteroid use

• History of macrosomic

infant

• Current fetal macrosomia

or polyhydramnios

[Grade D, Consensus]

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Recommendation 18: Diagnosis of GDM

18.The preferred approach for the screening and

diagnosis of GDM is the following [Grade D, Consensus]:

a) Screening for GDM should be conducted using the 50 g

glucose challenge test (GCT) administered in the non-

fasting state with plasma glucose measured one hour later

[Grade D, Level 4]. A plasma glucose value ≥7.8 mmol/L at

one hour will be considered a positive screen and will be

an indication to proceed to the 75 gram OGTT [Grade C, Level

2]. A plasma glucose value >11.1 mmol/L can be

considered to be diagnostic of gestational diabetes and

does not require a 75 gram OGTT for confirmation [Grade C,

Level 3].

2013



Recommendation 18: Diagnosis of GDM

(continued)

b) If the GCT screen is positive, a 75 gram OGTT

should be performed as the diagnostic test for

GDM using the following criteria: >1 of the

following values:

– Fasting >5.3 mmol/L,

– 1h >10.6 mmol/L,

– 2h >9.0 mmol/L

[Grade B, Level 1]

2013



GDM: Glycemic Management During Pregnancy

• Perform SMBG, both fasting and postprandially

• Glycemic Targets during pregnancy:

• Receive nutrition counseling

– Moderate carbohydrate restriction: 3 meals + 3 snacks

– Targets not met within 2 weeks start insulin

– Avoid hypocaloric diet weight loss + ketosis

Target glucose values

Fasting PG <5.3 mmol/L

1h postprandial PG <7.8 mmol/L

2h postprandial PG <6.7 mmol/L

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Pre-Pregnancy BMI Recommended range

of total weight gain

(Kg)

Recommended range

of total weight gain

(lb)

BMI <18.5 12.5 – 18.0 28 – 40

BMI 18.5 - 24.9 11.5 – 16.0 25 – 35

BMI 25.0 - 29.9 7.0 – 11.5 15 – 23

BMI > or = 30 5.0 – 9.0 11 – 20

Recommended rate of weight gain and total weight gain for singleton

Pregnancies according to pre-pregnancy BMI

IOM Guidelines for Gestational Weight Gain

Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus

Report. May 2009. The National Academies Press. Washington, DC.



Postpartum GDM Management Checklist

1. Encourage Breastfeeding

2. 75g OGTT between 6 weeks - 6 months

postpartum to detect prediabetes or diabetes

3. Discuss increased long-term risk of diabetes –

Importance of returning to pre-pregnancy weight



Recommendation 20: Management During

Pregnancy (GDM)

20.Women with GDM should:

a. Strive for target glucose values:

– Fasting PG below 5.3 mmol/L [Grade B, Level 2]

– 1h postprandial below 7.8 mmol/L [Grade B, Level 2]

– 2h postprandial below 6.7 mmol/L [Grade B, Level 2]

b. Perform SMBG, both fasting and postprandially to

achieve glycemic targets and improve pregnancy

outcomes [Grade B, Level 2]

c. Avoid ketosis during pregnancy [Grade C, Level 3]

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Pregnancy (GDM)

21.Receive nutrition counseling from a registered

dietitian during pregnancy [Grade C, Level 3] and

postpartum [Grade D, Consensus]. Recommendations for

weight gain during pregnancy should be based on

pregravid BMI [Grade D, Consensus].



Recommendation 22 and 24: Management

During Pregnancy (GDM)

22.If women with GDM do not achieve glycemic targets

within 2 weeks from nutritional therapy alone,

insulin therapy should be initiated [Grade D, Consensus].

23.Insulin therapy in the form of multiple injections

should be used [Grade A, Level 1].

24.Rapid-acting bolus analog insulin may be used

over regular insulin for postprandial glucose control

although perinatal outcomes are similar [Grade B, Level 2].

2013




Pregnancy (GDM)

25.For women who are non-adherent to or who refuse

insulin, glyburide [Grade B, Level 2] or metformin [Grade B,

Level 2] may be used as alternative agents for

glycemic control. Use of oral agents in pregnancy is

off-label and this should be discussed with the

patient [Grade D, Consensus].

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Recommendation 26: Intrapartum

Management (GDM)

26.Women should be closely monitored during labour

and delivery and maternal blood glucose levels

should be kept between 4.0 and 7.0 mmol/L in

order to minimize the risk of neonatal hypoglycemia. [Grade D, Consensus]

26.Women should receive adequate glucose during

labour in order to meet the high energy requirements [Grade D, Consensus].

2013

2013



Recommendation 28: Postpartum (GDM)

28.Women with GDM should be encouraged to

breastfeed immediately after delivery in order to

avoid neonatal hypoglycemia [Grade D, Level 4] and to

continue for at least three months postpartum in

order to prevent childhood obesity [Grade C, Level 3] and

reduce risk of maternal hyperglycemia [Grade C, Level 3].

29.Women should be screened with a 75g OGTT

between 6 weeks and 6 months postpartum to

detect prediabetes and diabetes [Grade D, Consensus].

2013



CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://guidelines.diabetes.ca/

http://diabetes.ca/

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